Inspection on 08/12/05 for Fengates (1)

This inspection was carried out on 8th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Fengates (1) 03/04/09

Fengates (1) 03/04/07

Fengates (1) 25/07/05

Fengates (1) 01/12/04

Fengates (1) 05/07/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Fengates (1) 1 Fengates Redhill Surrey RH1 6AH Lead Inspector Lisa Johnson Announced Inspection 8th December 2005 10:00 Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fengates (1) Address 1 Fengates Redhill Surrey RH1 6AH 01737 778811 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) CMG Homes Ltd Miss Kate Charlotte Webber Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (2) of places Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Home may accommodate up to 2 residents with both LD and MD within the total number of residents accommodated The age/age range of the persons to be accommodated will be 19 TO 45 YEARS 25th July 2005 Date of last inspection Brief Description of the Service: 1 Fengates is owned by Care Management Group. The home is a detached property providing accommodation to six adults who have learning disabilities. The home is located in Redhill, Surrey. The home is accessible to local shops and public transport. Redhill town centre is close by. The accommodation is provided over two floors. All bedrooms are single with en-suite showers. There is a comfortable lounge, separate dining room and a large kitchen. There is a patio area and a small garden that is laid with lawn to the rear of the house. Parking is available at the front of the house. Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second inspection for 2005/2006. One inspector carried out the announced inspection over four and half hours. The focus of the inspection was to review any requirements made at the last inspection and to look at other required standards. A tour of the premises took place. Care plans, policies and procedures and other required documentation were sampled. The inspector met with three service users and spoke to the registered manager and two members of staff. Comment cards were received from five service users. These comments are reflected in this report. This was a positive inspection. The inspector would like to thank the service users and staff for their hospitality and cooperation in carrying out this inspection. What the service does well: The home has a warm, welcoming and friendly atmosphere. The home is decorated and furnished to a good standard. It was clear that staff have a good knowledge and understanding of the needs of the service users. Care plans; review meetings, personal goals and risk assessments for individuals were detailed and comprehensive and were drawn up with the involvement of service users. This was confirmed by comments received from individuals. It was pleasing to see that service users are able to make decisions about their lives with assistance when needed. One service user spoken to said “It’s a pretty good here” and another service user described the staff as “brilliant”. Written comments received confirmed that those who provided feedback are happy living in the home and describe the home as,” homely and the staff are kind”. Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&3 Comprehensive information was available that would assist prospective service users and relatives make an informed choice as to whether the home would be a suitable place to live. The individual needs of service users are assessed. EVIDENCE: The home has revised its Statement of purpose, which was very detailed, and comprehensive clearly describing the aims and objectives of the home and the services it is able to provide. A new service user has been admitted to the home as an emergency and it was evident that the registered manager is gathering information to complete an assessment, which was in progress. Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 & 10 Each service user is provided with a completed care plan that is based on assessment. The home is able to demonstrate that goal plans are reviewed and that individuals are involved and consulted in the review process. Service users are supported to make decisions. Confidential information is handled appropriately. EVIDENCE: Two care plans were sampled and were of a good standard. It was clear that plans and personal goals were based on assessment. Service users are involved and consulted in respect of their care plans, which were signed, by them and their key workers. Five comments received from service users confirmed that they are able to participate in meetings to talk about what is good and what should be changed. Two staff spoken to confirmed their role in the care planning process. One example was for an individual who wanted to go to the gym; this was then recorded as a personal goal. Monthly reviews were recorded in detail, which provided accurate evidence on the progress of individual goals. Personal goals achieved were recorded in consultation with service users. One individual spoken to maintains notes of his meetings. Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 10 A comprehensive range of risk assessments were in place covering life skills, social and emotional needs. Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 16 & 17 The home is able to demonstrate that service users are supported to take part in appropriate activities and have a range of leisure activities. Service users rights and responsibilities are respected. Service users are offered a well balanced diet. EVIDENCE: Service users confirmed that they engage in a range of recreational and social activities. One individual is employed at a riding school. Some individuals attend classes at East Surrey College. One person has his own computer in his bedroom with a range of equipment, which he was very proud of and showed the inspector some of the work he has been undertaking. Aromatherapy sessions are held in the home and one individual goes to the local gym. Service users have been away on holidays or long weekends. Each individual has an opportunity during the week to take part in household activities. Each person had their own cleaning equipment basket, which was for their personal use and one person spoken to said he likes to help cook. Staff and service users were seen interacting with each other in a relaxed, friendly and informal atmosphere and were all enjoying making Christmas Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 12 cards and having lunch together. All service users have their own front door and bedroom Keys. Service users have unrestricted access in the home and can help themselves to drinks and snacks. Comments received from the service users indicate that their privacy is respected. Although the main meal wasn’t seen at the time of the inspection there is menu plan in place, which was seen to offer a well-balanced and nutritious diet. Service users were offered a choice of snacks at lunchtime and comments received from service users indicate that choices of meals are accommodated. Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 21 The home is able to demonstrate that resident’s health and emotional needs are met. The wishes of each individual in respect of dying and death has been discussed with them in a sensitive manner and a recorded plan is in place EVIDENCE: The home is introducing health care action plans and one plan was sampled which clearly details the health needs of individuals and support required to access primary health care specialists and appointments. Individual plans were in place in respect of dealing with ageing and death. This has been discussed with each individual with sensitivity. Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The home is able to demonstrate that complaints are followed up. Adequate policies and procedures are in place in respect of the protection of vulnerable adults. However the home should ensure that staff receive up to date training to ensure that service user are protected from abuse. EVIDENCE: A complaints procedure is in place, which is in a service user-friendly format. The complaints register was sampled and it was clear that the registered manager follows up any issues raised appropriately. One service user spoken to stated, “ It’s a pretty good here”. Another service user said the staff are “brilliant”. Comment cards received from service users confirm that they know who they could talk to if they had concerns, feel safe and are happy living in the home. Adequate policies and procedures are in place in respect of protection of vulnerable adults. There was some evidence that staff have received appropriate training in this area. However a number of staff require up-todate training. A requirement was made that this must be completed. This is to ensure that staff have acquired information to protect service users from abuse. Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28, 29 & 30 Service users live in a homely and comfortable environment. A separate smoking area should be provided and consideration should be given to expanding the office. The home was able to demonstrate that service users live in a clean and hygienic home. EVIDENCE: The home is located to nearby shops and facilities. A tour of the home took place. The service has a homely, bright and warm atmosphere. Service users live in a well maintained, furnished home. However the home needs to consider providing a separate area for service users who wish to smoke, as one service user has to smoke inside the entrance to the house. The inspector was informed that the company is planning to install a conservatory. It was requested that the timescale for completion of this work should be provided to the Commission for Social Care Inspection. It was also requested in respect of the staff office, which is small and cramped, which makes it difficult for any private consultation to take place. The timescale for completion of this work also be provided to the Commission for Social Care Inspection. The service users presently living at the home do not require specialist equipment. The home was cleaned to a high standard and was hygienic. Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 16 Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32, 34, 35 & 36 Staff are aware of their roles and responsibilities. Staff were supported to undertake training and development. Service users are protected by the homes recruitment policies and procedures. All staff receive formal supervision. EVIDENCE: All staff have been issued with job descriptions, which were sampled, on personnel files. Staff are made familiar with the standards of conduct and practice set out by the General Social Care Council (GSCC). Staff training records were sampled and it was clear that staff receive appropriate training to support the service users in the home. The manager is presently introducing a separate training schedule for all staff. Evidence was available on staff personal files that staff receive induction training. A staff resource file has been introduced by the manager, which provides detailed information on all aspects of the home. Staff files were sampled and were found to have all of the required information including a record of police check numbers. A number of staff have completed or are completing National Vocational Qualifications including the registered manager who is near to completing the Registered Managers Award. This will ensure that fifty percent of staff will have achieved a National Vocational Qualification. Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 18 Staff receive annual appraisals and supervision records were sampled. All staff receive formal supervision from the manager, which was recorded. Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 40, 41, 42 & 43 The home has implemented a quality assurance system based on seeking the views of residents. The registered manager has implemented policies and procedures that are dated and signed for by staff. The health, welfare and safety of residents and staff is protected and promoted. Service users are protected by the financial procedures of the home. EVIDENCE: A quality assurance system was in place based on feedback questionnaires. Outcomes are fed back to service users and the company holds an annual forum. The home regularly consults with service users by holding service user meetings. The responsible individual carries out monthly quality visits. A range of policies and procedures were in place. A read and sign system is in place. Service users have their own bank accounts. Health and safety checks had been carried out. On the day of the inspection a number of samples were taken that confirmed the information provided regarding those checks for example accident records, Legionella testing and Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 20 water temperatures which are checked weekly, accident records, fridge and freezer temperatures and first aid box. Fire records were examined with evidence of weekly fire alarm, drills and emergency lighting checks being recorded. A business plan was available. The company holds the overall budget but the manager maintains a budget for the home, which she has responsibility for including staffing and training. Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 3 X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 X X 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fengates (1) Score X 3 X 3 Standard No 37 38 39 40 41 42 43 Score X X 3 3 3 3 3 DS0000013437.V259352.R01.S.doc Version 5.0 Page 22 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA 23 Regulation 13(6) Requirement The registered manager must ensure that all staff receive update training in the protection of vulnerable adults. This is to ensure that staff have the up-todate information to ensure that service users are protected from abuse Timescale for action 08/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA 28 Good Practice Recommendations It is requested that the company should consider providing dates for the completion of the conservatory and for the expansion of the office to the Commission for Social Care Inspection. Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Fengates (1) DS0000013437.V259352.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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